Failure to Follow Infection Control Standards and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection control standards in multiple instances. On one hall, a resident was observed handling various items in a PPE cart, including masks and a stethoscope, for several minutes without staff intervention or subsequent sanitization of the cart. Although a staff member was present during the incident, no immediate action was taken to prevent the resident from touching the items or to clean the cart afterward. Staff later acknowledged that this did not align with infection control protocols. Additionally, on the same hall, a water pitcher cart was found near a room under enhanced barrier precautions (EBP) with an uncovered ice scoop and a soiled cup placed next to clean items, such as gloves and straws. Staff admitted that it was difficult to prevent residents from placing dirty items on the cart and that the presence of soiled items was not in line with best practices. Furthermore, a resident with open wounds requiring daily and twice-daily wound care did not have appropriate EBP signage posted outside their room, and multiple staff members provided care without donning PPE. Staff involved were unaware of the need for precautions and confirmed that care plans and signage were not consistently updated.